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Gastro-pleuro-cutaneous fistula following gunshot wound
GASTRO#PLEUROCUTANEOUS FISTULA FOLLOWING GUNSHOT WOUND CASE
REPORT
W. H. PARSONS, M.D., F.A.C.S. AND W.
G.
WESTON,
M.D.
VICKSBURG, MISS.
G
UNSHOT wounds of the upper abdomen are fairIy common. Coincident to such injuries, damages to the intra-abdomina1 organs may occur considered shouId aIways be and possibiIities. It is particuIarIy important to know or to determine, when possibIe, the position of the patient at the time the wound was received and the apparent angIe at which the buIIet has entered. This is particuIarIy true in cases where the missiIe does not emerge from the body. The buIIet may take a downward, a straight, a IateraI or an upward course depending on the angIe at which it penetrates, its veIocity and the structures with which it comes in contact. Thus it may enter the chest, range downward and damage one or more of the abdomina1 viscera or it may enter the abdomen primariIy, range upward, and invade the thoracic cavity, with or without injury to the structures contained therein. ShipIey’ states that a fairIy common suicide injury is caused by a buIIet passing beIow and to the outer side of the heart, penetrating the Iung, piercing the diaphragm and wounding the stomach, spIeen or Ieft kidney. Gastro-pIeuro-cutaneous fistuIa foIIowing a gunshot wound is apparentIy a reIativeIy uncommon condition. In a recent rather extensive survey of the Iiterature, no case reports of this condition were found by us. Graham,2 LiIientha13 and HedbIom4 state 1ShipIey, A. M. In: Lewis. Practice of Surgery. Hagerstown, Md., Prior, 4: Chap. IO. 2Graham, E. A. Personal communication. 3LiIienthaI, H. Persona1 communication. 4 HedbIom, C. A. Personal communication.
that they have had no personal experience with such a case. It was suggested by Graham that possibIy such a case report could be found in the records of the MedicaI Corps of the U. S. Army, but review faiIed to find mention of the condition. CASE REPORT L. S., singIe, femaIe, coIored, aged twentythree, admitted to Vicksburg HospitaI December 27, 1931. Chief Complaint. Shortness of breath foIIowing gunshot wound. Present Illness. The patient was shot in the Ieft side of the chest two days previous to admission, and according to the patient and her reIatives the person firing the shot was on the same IeveI with the patient and shot her whiIe she was standing. ImmediateIy after the injury, the patient became short of breath and noticed a sucking sound with respiration. She was treated eIsewhere for two days and was then brought to the Vicksburg HospitaI. At the time of admission she was compIaining of marked dyspnea and of inabiIity to breathe whiIe IYing down. Previous Health. Had always been good. There had been no serious past iIInesses and no previous injuries. Family History. Not remarkabIe. History by Systems. Negative. Physical Examination. Temperature 102’F. p uIse rate 140. Respiratory rate 44. Inspection reveaIed a we&developed but poorIy nourished femaIe coIored aduIt, acuteIy III and compIaining of shortness of breath and of inabihty to breathe whiIe Iying down. There was a sucking sound present with respiration. Head. Not remarkable. Mouth. Neck. right.
458
DentaI caries; otherwise negative. The trachea was dispIaced to the
Parsons & Weston-FistuIa Chest. Inspection: AnteriorIv, I in the fifth interspace, 4 cm. from the midsterna line, there was a wound 0.75 cm. in diameter due to the recent gunshot injury. The wound had closed. Posteriorly, just heIow the inferior angIe of the scapula in the eighth interspace, there was an open wound 2 cm. in diameter, from which shreads of tissue were hanging, and from which ;I smali amount of clear fluid was escaping. Lungs. Inspection showed marked limitation of expansion on the left and rapid shaIIow respiration; the rate was 44 per minute. There \~ns a plainIv audibIe sucking sound present \vith respiration. PaIpation reveaIed the absence of tactile fremitus over the entire left lung and an apparent increase above norma on the opposite side. A decrease in the width of the intercosta1 spaces was aIso noted on the left side. The percussion note was hyperresonant throughout the Ieft chest with the exception of slight duIIness posteriorly in the interscapuIar area. The note was resonant throughout on the right side. Auscultation. Sounds were obscured by a sucking noise present with respiration, but breath sounds were practicaIIy absent on the left and somewhat increased on the right. VocaI fremitus was also markedIy diminished on the Ieft. No &es were heard in either Iung. Heart. Inspection showed a visibIe puIsation of the apex in the fourth interspace, 3.5 cm. from the mid-sterna1 Iine. PaIpation confirmed the inspection in the Iocation of the apex beat. No thriIIs or shocks were feIt. Percussion of the heart reveaIed dispIacement of that organ 3 cm. to the right of the midsternal Iine in the fourth interspace. Percussion to the left confirmed the inspection and palpation. AuscuItation reveaIed a rate of 140, with regular rhythm and without murmurs. BIood pressure: Systolic I 12, diastolic 76. AbdominaI exammation reveaIed a sIight rigidity of the Ieft rectus in its upper half, with onIy sIight tenderness. The remainder of the abdomina1 examination showed nothing remarkable. Vaginal examination reveaIed nothing of significance. Extremities were not remarkabIe. Nervous System. RefIexes were active and equa1 on the two sides. Gordon, Oppenheim and Babinski reactions negative. Laboratorv Findings. Blood for Kline and J’oung reactions was negative. Blood for Kahn reaction was negative.
Amcricnn
Journal
of Surgcrb
-139
Blood: Some pIateIets; hemogIobin 60 SahIi; slight anisocytocis; slight poikilocytocis; sIight poIychromatophiIia; rare microcytes; rare macrocytes; rare normoblasts; Icucocytes 17; Iarge monoI 1,700; smaI1 Iymphocytes nucIears 6; neutrophiIes 77 (45 B.F.). BIood Chemistry. Chlorides, &8.-$ mg. per I00 C.C. Specimen I 75 C.C. CoIor dark green; Urine. reaction slightly acid; appearance cloudy; Sp. Gr. 1.022; indican Iarge trace; albumin Iarge trace; Sugar none; fern-- round cpitheIia1 cells; sediment 2 per cent sIightIy heavy yeIIow; epithelial ~~11s; some numerous squamous bacilli present. Progress Notes. Dec. 27, 193 I. A tentative diagnosis of traumatic pneumothorax, Ieft side, was made. The patient was treated conservativeIy because of the gravity of her condition and the evidence of toxlcity present. Morphine suIphate gr. s/4 was given repeatedly, fluids in Iarge amounts by mouth were forced and smaI1 amounts of I0 per cent gIucose in the vein were given cautiousIy. The wounci in the chest was seaIed with rubber dam and coIIodion. Dec. 28, 1931. The patient’s condition seemed somewhat improved. FIuids were given more freeIy by mouth and in the vein. The temperature, puIse and respiration remained about the same. The amount of urine voided seemed to be considerabIy below the fluid intake. Three hundred cubic centimeters of titrated bIood were given in the vein. VenocIysis was started. Dec. 30, 1931. Th e condition of the patient was about the same. Venoclysis was discontinued. FIuid intake 5310 C.C. Urinary- output 930 C.C. It was noted that the bed was extremeIy wet at a11 times although the patient was not incontinent. The rubber dam and coIIodion had come off and the dressing over the Mound was wet. The possibility of a gastro-pleurocutaneous fistuIa presented itself. AccordingI\:, 500 C.C. of water, coIored with meth\Icne blue, were given by stomach tube, and w&in a few minutes the coIorec1 SoIution was seen coming from the wound in the back. Treatment. The question of treatment next presented itseIf. In view of the poor condition of the patient, it was decided to treat her conservatively, hoping that surgery couId be done later. A semi-FowIer position was instituted and fluids by mouth were discontinued, a11 fluids being given subcutaneously or intra-
American Journal of Surgery
460
Parsons
& Weston-FistuIa
keeping the fluid intake above in twenty-four hours. Jan. 3, 1932. The patient was showing no improvement; the heart rate remaining persistentIy high (140 or over). The patient had been digitaIized. The respiratory rate aIso remained eIevated. Surgery was decided on in the hope of cIosing the stomach wound. It was pIanned at the earIiest possibIe time, folIowing this procedure, to cIose the wound in the chest, instituting cIosed drainage. We then proposed to divide the Ieft phrenic nerve and repair the diaphragmatic wound. The sequence outIined appeared to us to offer the best soIution to the severa probIems present. Jan. 4, 1932. Operation was done under IocaI anesthesia by one of us (W. H. P.). Closure of Perforations of Stomach. Jejunostomy. LocaI anesthesia was induced in the usua1 manner. The abdomen was opened through a transrectus incision just to the Ieft of the mid-Iine. When the abdomen was opened, the stomach was found to be situated rather high; and when the Iesser peritonea1 cavity was entered, a diffuse peritonitis was found. The posterior waI1 of the stomach, just above the greater curvature and at about its mid-portion, was firmIy attached to the diaphragm. The adhesions were separated and venousIy, 2000
C.C.
SEPrEMann,,933
two perforations of the stomach were found, one being near the cardia and quite diffIcuIt of approach. The perforation adjacent to the pyIorus was suficientIy Iarge to admit the IittIe finger. Th is perforation was adherent to the left Iobe of the Iiver and extended through the diaphragm. The tissues were rather crisp. The second perforation was more to the Ieft, and was smaIIer. Both perforations were closed with bIack silk and the suture Iines were protected by omentum. No attempt was made at this time to repair the diaphragmatic defect. VaseIine gauze was packed IightIy into the opening. A rubber dam was inserted between the stomach and diaphragm and the packing and rubber tissue emerged to serve as a drain. The usua1 wound repair was done. The patient toIerated the operation fairIy weI1. Soon after her return from surgery, however, the heart rate increased to 168, the temperature to IOjd’F. and the respirations to 44 per minute. was treated Jan. 5, 1932. The patient throughout the night for hyperpyrexia, with coo1 sponges, ice caps and aIcoho1 rubs, without effect, and death occurred at 8355 A.M., twentyfour hours after operation and eIeven days after the origina injury. Permission for a post mortem was denied.
REPORT
W. H. PARSONS, M.D., F.A.C.S. AND W.
G.
WESTON,
M.D.
VICKSBURG, MISS.
G
UNSHOT wounds of the upper abdomen are fairIy common. Coincident to such injuries, damages to the intra-abdomina1 organs may occur considered shouId aIways be and possibiIities. It is particuIarIy important to know or to determine, when possibIe, the position of the patient at the time the wound was received and the apparent angIe at which the buIIet has entered. This is particuIarIy true in cases where the missiIe does not emerge from the body. The buIIet may take a downward, a straight, a IateraI or an upward course depending on the angIe at which it penetrates, its veIocity and the structures with which it comes in contact. Thus it may enter the chest, range downward and damage one or more of the abdomina1 viscera or it may enter the abdomen primariIy, range upward, and invade the thoracic cavity, with or without injury to the structures contained therein. ShipIey’ states that a fairIy common suicide injury is caused by a buIIet passing beIow and to the outer side of the heart, penetrating the Iung, piercing the diaphragm and wounding the stomach, spIeen or Ieft kidney. Gastro-pIeuro-cutaneous fistuIa foIIowing a gunshot wound is apparentIy a reIativeIy uncommon condition. In a recent rather extensive survey of the Iiterature, no case reports of this condition were found by us. Graham,2 LiIientha13 and HedbIom4 state 1ShipIey, A. M. In: Lewis. Practice of Surgery. Hagerstown, Md., Prior, 4: Chap. IO. 2Graham, E. A. Personal communication. 3LiIienthaI, H. Persona1 communication. 4 HedbIom, C. A. Personal communication.
that they have had no personal experience with such a case. It was suggested by Graham that possibIy such a case report could be found in the records of the MedicaI Corps of the U. S. Army, but review faiIed to find mention of the condition. CASE REPORT L. S., singIe, femaIe, coIored, aged twentythree, admitted to Vicksburg HospitaI December 27, 1931. Chief Complaint. Shortness of breath foIIowing gunshot wound. Present Illness. The patient was shot in the Ieft side of the chest two days previous to admission, and according to the patient and her reIatives the person firing the shot was on the same IeveI with the patient and shot her whiIe she was standing. ImmediateIy after the injury, the patient became short of breath and noticed a sucking sound with respiration. She was treated eIsewhere for two days and was then brought to the Vicksburg HospitaI. At the time of admission she was compIaining of marked dyspnea and of inabiIity to breathe whiIe IYing down. Previous Health. Had always been good. There had been no serious past iIInesses and no previous injuries. Family History. Not remarkabIe. History by Systems. Negative. Physical Examination. Temperature 102’F. p uIse rate 140. Respiratory rate 44. Inspection reveaIed a we&developed but poorIy nourished femaIe coIored aduIt, acuteIy III and compIaining of shortness of breath and of inabihty to breathe whiIe Iying down. There was a sucking sound present with respiration. Head. Not remarkable. Mouth. Neck. right.
458
DentaI caries; otherwise negative. The trachea was dispIaced to the
Parsons & Weston-FistuIa Chest. Inspection: AnteriorIv, I in the fifth interspace, 4 cm. from the midsterna line, there was a wound 0.75 cm. in diameter due to the recent gunshot injury. The wound had closed. Posteriorly, just heIow the inferior angIe of the scapula in the eighth interspace, there was an open wound 2 cm. in diameter, from which shreads of tissue were hanging, and from which ;I smali amount of clear fluid was escaping. Lungs. Inspection showed marked limitation of expansion on the left and rapid shaIIow respiration; the rate was 44 per minute. There \~ns a plainIv audibIe sucking sound present \vith respiration. PaIpation reveaIed the absence of tactile fremitus over the entire left lung and an apparent increase above norma on the opposite side. A decrease in the width of the intercosta1 spaces was aIso noted on the left side. The percussion note was hyperresonant throughout the Ieft chest with the exception of slight duIIness posteriorly in the interscapuIar area. The note was resonant throughout on the right side. Auscultation. Sounds were obscured by a sucking noise present with respiration, but breath sounds were practicaIIy absent on the left and somewhat increased on the right. VocaI fremitus was also markedIy diminished on the Ieft. No &es were heard in either Iung. Heart. Inspection showed a visibIe puIsation of the apex in the fourth interspace, 3.5 cm. from the mid-sterna1 Iine. PaIpation confirmed the inspection in the Iocation of the apex beat. No thriIIs or shocks were feIt. Percussion of the heart reveaIed dispIacement of that organ 3 cm. to the right of the midsternal Iine in the fourth interspace. Percussion to the left confirmed the inspection and palpation. AuscuItation reveaIed a rate of 140, with regular rhythm and without murmurs. BIood pressure: Systolic I 12, diastolic 76. AbdominaI exammation reveaIed a sIight rigidity of the Ieft rectus in its upper half, with onIy sIight tenderness. The remainder of the abdomina1 examination showed nothing remarkable. Vaginal examination reveaIed nothing of significance. Extremities were not remarkabIe. Nervous System. RefIexes were active and equa1 on the two sides. Gordon, Oppenheim and Babinski reactions negative. Laboratorv Findings. Blood for Kline and J’oung reactions was negative. Blood for Kahn reaction was negative.
Amcricnn
Journal
of Surgcrb
-139
Blood: Some pIateIets; hemogIobin 60 SahIi; slight anisocytocis; slight poikilocytocis; sIight poIychromatophiIia; rare microcytes; rare macrocytes; rare normoblasts; Icucocytes 17; Iarge monoI 1,700; smaI1 Iymphocytes nucIears 6; neutrophiIes 77 (45 B.F.). BIood Chemistry. Chlorides, &8.-$ mg. per I00 C.C. Specimen I 75 C.C. CoIor dark green; Urine. reaction slightly acid; appearance cloudy; Sp. Gr. 1.022; indican Iarge trace; albumin Iarge trace; Sugar none; fern-- round cpitheIia1 cells; sediment 2 per cent sIightIy heavy yeIIow; epithelial ~~11s; some numerous squamous bacilli present. Progress Notes. Dec. 27, 193 I. A tentative diagnosis of traumatic pneumothorax, Ieft side, was made. The patient was treated conservativeIy because of the gravity of her condition and the evidence of toxlcity present. Morphine suIphate gr. s/4 was given repeatedly, fluids in Iarge amounts by mouth were forced and smaI1 amounts of I0 per cent gIucose in the vein were given cautiousIy. The wounci in the chest was seaIed with rubber dam and coIIodion. Dec. 28, 1931. The patient’s condition seemed somewhat improved. FIuids were given more freeIy by mouth and in the vein. The temperature, puIse and respiration remained about the same. The amount of urine voided seemed to be considerabIy below the fluid intake. Three hundred cubic centimeters of titrated bIood were given in the vein. VenocIysis was started. Dec. 30, 1931. Th e condition of the patient was about the same. Venoclysis was discontinued. FIuid intake 5310 C.C. Urinary- output 930 C.C. It was noted that the bed was extremeIy wet at a11 times although the patient was not incontinent. The rubber dam and coIIodion had come off and the dressing over the Mound was wet. The possibility of a gastro-pleurocutaneous fistuIa presented itself. AccordingI\:, 500 C.C. of water, coIored with meth\Icne blue, were given by stomach tube, and w&in a few minutes the coIorec1 SoIution was seen coming from the wound in the back. Treatment. The question of treatment next presented itseIf. In view of the poor condition of the patient, it was decided to treat her conservatively, hoping that surgery couId be done later. A semi-FowIer position was instituted and fluids by mouth were discontinued, a11 fluids being given subcutaneously or intra-
American Journal of Surgery
460
Parsons
& Weston-FistuIa
keeping the fluid intake above in twenty-four hours. Jan. 3, 1932. The patient was showing no improvement; the heart rate remaining persistentIy high (140 or over). The patient had been digitaIized. The respiratory rate aIso remained eIevated. Surgery was decided on in the hope of cIosing the stomach wound. It was pIanned at the earIiest possibIe time, folIowing this procedure, to cIose the wound in the chest, instituting cIosed drainage. We then proposed to divide the Ieft phrenic nerve and repair the diaphragmatic wound. The sequence outIined appeared to us to offer the best soIution to the severa probIems present. Jan. 4, 1932. Operation was done under IocaI anesthesia by one of us (W. H. P.). Closure of Perforations of Stomach. Jejunostomy. LocaI anesthesia was induced in the usua1 manner. The abdomen was opened through a transrectus incision just to the Ieft of the mid-Iine. When the abdomen was opened, the stomach was found to be situated rather high; and when the Iesser peritonea1 cavity was entered, a diffuse peritonitis was found. The posterior waI1 of the stomach, just above the greater curvature and at about its mid-portion, was firmIy attached to the diaphragm. The adhesions were separated and venousIy, 2000
C.C.
SEPrEMann,,933
two perforations of the stomach were found, one being near the cardia and quite diffIcuIt of approach. The perforation adjacent to the pyIorus was suficientIy Iarge to admit the IittIe finger. Th is perforation was adherent to the left Iobe of the Iiver and extended through the diaphragm. The tissues were rather crisp. The second perforation was more to the Ieft, and was smaIIer. Both perforations were closed with bIack silk and the suture Iines were protected by omentum. No attempt was made at this time to repair the diaphragmatic defect. VaseIine gauze was packed IightIy into the opening. A rubber dam was inserted between the stomach and diaphragm and the packing and rubber tissue emerged to serve as a drain. The usua1 wound repair was done. The patient toIerated the operation fairIy weI1. Soon after her return from surgery, however, the heart rate increased to 168, the temperature to IOjd’F. and the respirations to 44 per minute. was treated Jan. 5, 1932. The patient throughout the night for hyperpyrexia, with coo1 sponges, ice caps and aIcoho1 rubs, without effect, and death occurred at 8355 A.M., twentyfour hours after operation and eIeven days after the origina injury. Permission for a post mortem was denied.